My new book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available!
Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Sunday, June 26, 2016

Health care is pretty complicated, and insurance coverage is
even harder to understand.This is the message that comes through clearly from
the interviews being done by Dr. Paul Gordon and recorded on his blog, https://bikelisteningtour.wordpress.com.
Dr. Gordon is taking a unique sabbatical, riding his bicycle across the country
from Washington (DC) to Washington (state), interviewing regular people, mostly
in cafés and such, about their take on Obamacare.

Here is something that is easy to understand, however: when
you call “911” as you have been trained to do in an emergency, and they don’t
come. Or they don’t come for a long time. Or they come with inadequate
supplies. Who do you get angry with when you, or your loved one, dies? The
government? They are surely in part at fault, even though they probably
contracted the service out, to save money, probably because voters want to pay
less tax. But there is another reason, explained in an excellent special
article in the New York Times, “When
you dial 911 and Wall St. answers” (June 26, 2016). The piece, by Danielle
Ivory, Ben Protess, and Kitty Bennett, details how many city services,
including ambulance services, are provided by companies that are owned by “private
equity firms”. These are companies whose investment capital comes from wealthy
individuals and particularly from pension funds, unlike banks whose money comes
from depositors. They are even less
regulated than banks, and thus more able to pursue their core mission, making
profit:

Unlike other for-profit companies, which
often have years of experience making a product or offering a service, private
equity is primarily skilled in making money. And in many of these businesses,
The Times found, private equity firms applied a sophisticated moneymaking
playbook: a mix of cost cuts, price increases, lobbying and litigation.

Whoa. This is
starting to get complicated again. Banks vs. “private equity” vs. just plain
old for-profit businesses? They are really just different forms of for-profit,
and provide a stepwise progression, from public services operated by government
for the benefit of the people, to private companies that are contracted by
government to do a service but might care about doing it well, to having those
companies owned by banks who really just want to make a profit, to having them
owned by private equity companies who care about nothing but making a profit.
The photo accompanying the Times article
is of Lynn Tilton, owner of Patriarch Partners (an ironic name, given that she
is a woman), which owned the emergency services company TransCare that served
many East Coast communities. TransCare went bankrupt, leaving those communities
without emergency medical services. Ms. Tilton’s picture is accompanied by the
quote from her reality television stint “It’s
only men I strip and flip.” As a poster child, she could become the Martin
Shkreli of ripping off necessary public services the way he was of ripping off
consumers of life-saving drugs.

“The business of America,” Calvin
Coolidge is often paraphrased as saying, “is
business.” This perspective, that it is not about doing things that are
best for the American people, is based in a belief that capitalism – “business”
– will, through the magic of the market, eventually meet those needs. OK, maybe
not those of people at the margins, people too poor to buy, so maybe we need a
safety net. But most people. A similar statement appeared today in the print
edition of the Kansas City Star from
KC Mayor Sly James, discussing the controversy over replacing the terminals at
Kansas City International Airport with one big, new terminal. Surveys
consistently show that the large majority of Kansas Citians (84% in this
article, “Regarding
KCI’s future, city ponders a new flight path”) like the current
arrangement, with short security lines and easy access in and out from one
story terminals, but the airlines and big businesses do not. In the large-type
quote accompanying his picture in the print edition (but, along with the photo,
left out of the online edition), Mayor James said “The people of this city need to be convinced of what I believe is a
basic reality, that this airport is about a lot more than ‘how fast can you get out of your car and get to your gate?’” Right. Business interests first. Take
that, 84% of Kansas Citians!

Because they most
obviously involve life and death, emergency medical services and firefighting
(yes, firefighting too has been contracted out to companies owned by private
equity firms!) get the greatest play in the Times
article, but many other services (like water!) are in the same situation:
controlled by companies whose goal is to make a profit rather than to provide
effective service for people. This is what happens when municipalities are
starved of funds because people vote to cut taxes.

Whether it is
health insurance or emergency medical services or municipal water, the system
becomes very complicated and hard to understand when it is trying to meet conflicting
agendas. When the need for people to receive critical, health-producing service
(fire and police protection, clean water, garbage collection, ambulances) is
compromised by provisions built into contracts (or the law) for companies
(insurance companies, banks, private equity firms) to make profit. I guess it
is fine if these services can be effectively and reliably provided by
for-profit companies, but when their pursuit of profit through “a mix of cost
cuts, price increases, lobbying and litigation” conflict with actually
providing services, there is a big problem. In the case of emergency medical
services, the problem was that “…many newly insured Americans turned out to be
on Medicaid, according
to the Kaiser Family Foundation. Medicaid restricts
some of the most aggressive billing tactics.”

A variety of
other difficult to understand strategies are also employed at the macro level
to place the interests of wealthy corporations above those of the people. These
include the unlimited political contributions permitted by the Supreme Court’s Citizen’s United decision, incredible
gerrymandering of congressional districts so that we have states where the
majority of voters vote for Democrats but most districts are solidly Republican
(see the New York Times Book Review “Where
votes go to die”, June 26, 2016), and the provisions of the Trans-Pacific
Partnership (TPP) that prevent national governments from regulating
multi-national corporations.

We could solve
this if there was a single, over-arching principle, always codified into law,
that the interests of the people as a whole always trumps the profit potential
of corporations. I vote for that.

Saturday, June 18, 2016

The current generation of young adults, commonly called
“millennials”, is often criticized for being self-centered, “spoiled”, the
product of “helicopter parents”, showing the signs of having grown up in a
culture where “everyone was a winner”. On the other hand, studies also show
them to be the most socially conscious, idealistic, and optimistic generation
in a long time (despite the evidence that things are not going so well for
them, and little reason to think they’ll improve soon). They, as a group, have
become politically involved, shocking the established political order with
their enthusiasm for the presidential candidacy of an old Jewish socialist from
New York City via Vermont, making Sen. Sanders a viable contender

This generation includes most medical students, as well as
most residents, so I get to see them a lot. I can say that there are many in
this group who are committed, hard-working, idealistic and self-sacrificing.
And there are a lot who are not. In short, they are people. Yes, there are those
who, for whatever reasons in their personality or upbringing, are “all about
me”, argue their grades, have no time for giving to others, seem to have no
sense of the collective good, and sometimes make me wonder why they want to be
doctors. But you know what? We had those people back in my generation. I was in
college in the 1960s, and not pre-med, and there were pre-meds around who had
the reputation as narrow, grade-grubbing, and not socially involved. There were
also pre-meds who were very involved in the major struggles of the day,
anti-war, civil rights, racism. I was in a post-baccalaureate premedical
program in the early 1970s, when the Vietnam War, with its extension into
Cambodia, was peaking. Many of my fellow students, going to night classes after
working all day, could not be seen as privileged, but many, including veterans,
were active in those movements. And many were not.

I was in medical school in the mid-1970s, and there were
many who were all about themselves and their futures. And many whose futures
turned out to be very distinguished and productive. There was also a lot of
social involvement. Chicago had a number of medical schools, and students knew
each other across schools, even sometimes roomed together. When a physician
researcher at one school was discovered to be doing research that targeted poor
black women, students there protested; when he planned to leave for a job at
another school, students there made an issue of it. I was involved in some of
these struggles, and some in medical school. When, at a forum of the whole
school to discuss the impact of our 3-year curriculum, the Chairman of Surgery
announced he thought our 3rd-year medical students were ill-prepared
because he had heard some of them asking nurses for advice on skills such as
starting an IV (“in my day, we would never have asked nurses for advice!”), I stood up and spoke on how we were glad to not be like that, that we wanted to be
able to learn from anyone. Maybe not my smartest hour (the chair of another
department tried to get my year-old grade in his clerkship changed), but I
bring it up because there appeared to be generational differences then, as now.
I am not an expert on generational trends (for this I recommend the outstanding
book by Paul Taylor, “The Next America”[1]),
but looking back I also remember senior faculty who were very supportive of
progressive efforts; I think that then, as now, it is people who are different,
not really generations.

Our current and recent medical students at KU created and
continue to staff and work hard for the Jaydoc Student-run Free Clinic, which
provides care for folks with little or no money or insurance in the evenings;
succeeding classes, if not generations, have expanded the scope and impact of
the clinic. Students frequently volunteer for, and self-fund, trips to provide
care in poorer countries – and even sometimes in our own, for those left out of
our non-system of health care. (These trips are generically called “mission
trips” even when there is no explicit evangelical religious component; however,
many are indeed organized by religious organizations, and personed by students,
doctors and others motivated by their religious beliefs. I may not be a big fan
of religious evangelism, but I am a big fan of people doing good work!) Many of
our students are active in the community, in local as well as national
programs. They regularly volunteer for the school-based health clinic at a
local high school, named the Bulldoc for the school’s teams, the Bulldogs, by
the high school’s students (post-milennials?). The clinic itself was created by
a collaboration between the school, school district, community groups
(particularly pastors), medical school faculty, and students – in particular
one medical student, without whose efforts it would never have come to pass.

When I was young, and even in earlier generations, many students,
like other people, worked for the interests of others as well as themselves. Many
do so now. Others, it is sad (to me) to say, are indeed self-absorbed, and all
about themselves. Like other people, like doctors – and nurses and accountants
and steelworkers and retail clerks and unemployed people. We can only laud
those whose work demonstrates the “better angels” of human nature, and hope
that narrow, selfish behaviors will extinguish.

To those who are in medical school, I want to say “No, it is
not about you. It is about the people for whom you will be caring. And let’s
not forget what ‘caring’ means.” Sometimes I actually do. Maybe we should all
say, or at least think, that more often.

[1]
Taylor, P and the Pew Research Center, “The Next America: Boomers, Millennials,
and the Looming Generational Showdown”, 2014.